Re-examining health IT policy: what will it take to derive value from our investment?

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Bridging the Gap Between Academic Research and Pragmatic Needs in Usability: A Hybrid Approach to Usability Evaluation of Health Care Information Systems

BACKGROUND

Technology is increasingly embedded into the full spectrum of health care. This movement has benefited from the application of software development practices such as usability testing and agile development processes. These practices are frequently applied in both commercial or operational and academic settings. However, the relative importance placed on rapid iteration, validity, reproducibility, generalizability, and efficiency differs between the 2 settings and the needs and objectives of academic versus pragmatic usability evaluations.

OBJECTIVE

This paper explores how usability evaluation typically varies on key dimensions in pragmatic versus academic settings that impact the rapidity, validity, and reproducibility of findings and proposes a hybrid approach aimed at satisfying both pragmatic and academic objectives.

METHODS

We outline the characteristics of pragmatic versus academically oriented usability testing in health care, describe the tensions and gaps resulting from differing contexts and goals, and present a model of this hybrid process along with 2 case studies of digital development projects in which we demonstrate this integrated approach to usability evaluation.

RESULTS

The case studies presented illustrate design choices characteristic of our hybrid approach to usability evaluation.

CONCLUSIONS

Designed to leverage the strengths of both pragmatically and academically focused usability studies, a hybrid approach allows new development projects to efficiently iterate and optimize from usability data as well as preserves the ability of these projects to produce deeper insights via thorough qualitative analysis to inform further tool development and usability research by way of academically focused dissemination.

Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique

Background The development of new virtual care technologies (including telehealth and telemedicine) is growing rapidly, leading to a number of challenges related to health policy and planning for health systems around the world. Methods We brought together a diverse group of health system stakeholders, including patient representatives, to engage in policy dialogue to set health system priorities for the application of virtual care in the primary care sector in the Province of Ontario, Canada. We applied a nominal group technique (NGT) process to determine key priorities, and synthesized these priorities with group discussion to develop recommendations for virtual care policy. Methods included a structured priority ranking process, open-ended note-taking, and thematic analysis to identify priorities. Results Recommendations were summarized under the following themes: (a) identify clear health system leadership to embed virtual care strategies into all aspects of primary and community care; (b) make patients the focal point of health system decision-making; (c) leverage incentives to achieve meaningful health system improvements; and (d) building virtual care into streamlined workflows. Two key implications of our policy dialogue are especially relevant for an international audience. First, shifting the dialogue away from technology toward more meaningful patient engagement will enable policy planning for applications of technology that better meet patients' needs. Second, a strong conceptual framework on guiding the meaningful use of technology in health care settings is essential for intelligent planning of virtual care policy. Conclusions Policy planning for virtual care needs to shift toward a stronger focus on patient engagement to understand patients' needs.

Are We There Yet? Human Factors Knowledge and Health Information Technology - the Challenges of Implementation and Impact

Objective: To review the developments in human factors (HF) research on the challenges of health information technology (HIT) implementation and impact given the continuing incidence of usability problems and unintended consequences from HIT development and use. Methods: A search of PubMed/Medline and Web of Science® identified HF research published in 2015 and 2016. Electronic health records (EHRs) and patient-centred HIT emerged as significant foci of recent HF research. The authors selected prominent papers highlighting ongoing HF and usability challenges in these areas. This selective rather than systematic review of recent HF research highlights these key challenges and reflects on their implications on the future impact of HF research on HIT. Results: Research provides evidence of continued poor design, implementation, and usability of HIT, as well as technology-induced errors and unintended consequences. The paper highlights support for: (i) strengthening the evidence base on the benefits of HF approaches; (ii) improving knowledge translation in the implementation of HF approaches during HIT design, implementation, and evaluation; (iii) increasing transparency, governance, and enforcement of HF best practices at all stages of the HIT system development life cycle. Discussion and Conclusion: HF and usability approaches are yet to become embedded as integral components of HIT development, implementation, and impact assessment. As HIT becomes ever-more pervasive including with patients as end-users, there is a need to expand our conceptualisation of the problems to be addressed and the suite of tactics and strategies to be used to calibrate our pro-active involvement in its improvement.

Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange

BACKGROUND

Provider organizations increasingly have the ability to exchange patient health information electronically. Organizational health information exchange (HIE) policy decisions can impact the extent to which external information is readily available to providers, but this relationship has not been well studied.

OBJECTIVE

Our objective was to examine the relationship between electronic exchange of patient health information across organizations and organizational HIE policy decisions. We focused on 2 key decisions: whether to automatically search for information from other organizations and whether to require HIE-specific patient consent.

METHODS

We conducted a retrospective time series analysis of the effect of automatic querying and the patient consent requirement on the monthly volume of clinical summaries exchanged. We could not assess degree of use or usefulness of summaries, organizational decision-making processes, or generalizability to other vendors.

RESULTS

Between 2013 and 2015, clinical summary exchange volume increased by 1349% across 11 organizations. Nine of the 11 systems were set up to enable auto-querying, and auto-querying was associated with a significant increase in the monthly rate of exchange (P = .006 for change in trend). Seven of the 11 organizations did not require patient consent specifically for HIE, and these organizations experienced a greater increase in volume of exchange over time compared to organizations that required consent.

CONCLUSIONS

Automatic querying and limited consent requirements are organizational HIE policy decisions that impact the volume of exchange, and ultimately the information available to providers to support optimal care. Future efforts to ensure effective HIE may need to explicitly address these factors.

The Virtuous Circles of Clinical Information Systems: a Modern Utopia

CONTEXT

Clinical information systems (CIS) are developed with the aim of improving both the efficiency and the quality of care.

OBJECTIVE

This position paper is based on the hypothesis that such vision is partly a utopian view of the emerging eSociety.

METHODS

Examples are drawn from 15 years of experience with the fully integrated Georges Pompidou University Hospital (HEGP) CIS and temporal data series extracted from the data warehouses of Assistance Publique - Hôpitaux de Paris (AP-HP) acute care hospitals which share the same administrative organization as HEGP. Three main virtuous circles are considered: user satisfaction vs. system use, system use vs. cost efficiency, and system use vs quality of care.

RESULTS

In structural equation models (SEM), the positive bidirectional relationship between user satisfaction and use was only observed in the early HEGP CIS deployment phase (first four years) but disappeared in late post-adoption (≥8 years). From 2009 to 2013, financial efficiency of 20 AP-HP hospitals evaluated with stochastic frontier analysis (SFA) models diminished by 0.5% per year. The lower decrease of efficiency observed between the three hospitals equipped with a more mature CIS and the 17 other hospitals was of the same order of magnitude than the difference observed between pediatric and non-pediatric hospitals. Outcome quality benefits that would bring evidence to the system use vs. quality loop are unlikely to be obtained in a near future since they require integration with population-based outcome measures including mortality, morbidity, and quality of life that may not be easily available.

CONCLUSION

Barriers to making the transformation of the utopian part of the CIS virtuous circles happen should be overcome to actually benefit the emerging eSociety.

Circle of care modelling: an approach to assist in reasoning about healthcare change using a patient-centric system

Background

Many health system and health Information and Communication Technology (ICT) projects do not achieve their expected benefits. This paper presents an approach to exploring changes in the healthcare system to better understand the expected improvements and other changes by using a patient-centric modelling approach. Circle of care modeling (CCM) was designed to assist stakeholders in considering healthcare system changes using a patient centric approach.

Methods

The CCM approach is described. It includes four steps, based on soft systems methodology: finding out, conceptual modelling, structured discussion, and describing potential improvements. There are four visualizations that are used though this process: patient-persona based rich pictures of care flows (as part of finding out), and three models: provider view, communication view, and information repository view (as part of conceptual modelling).

Results

Three case studies are presented where CCM was applied to different real-world healthcare problems: 1. Seeking improvements in continuity of care for end of life patients. 2. Exploring current practices for medication communication for ambulatory patients prior to an update of a jurisdictional drug information system. 3. Deciding how to improve attachment of patients to primary care. The cases illustrate how CCM helped stakeholders reason from a patient centered approach about gaps and improvements in care such as: data fragmentation (in 1), coordination efforts of medication management (in 2), and deciding to support a community health centre for unattached patients (in 3).

Discussion

The circle of care modelling approach has proved to be a useful tool in assisting stakeholders explore health system change in a patient centric approach. It is one way to instantiate the important principle of being patient centered into practice when considering health system changes.

Clinical Information Systems - From Yesterday to Tomorrow

OBJECTIVES

To review the history of clinical information systems over the past twenty-five years and project anticipated changes to those systems over the next twenty-five years.

METHODS

Over 250 Medline references about clinical information systems, quality of patient care, and patient safety were reviewed. Books, Web resources, and the author's personal experience with developing the HELP system were also used.

RESULTS

There have been dramatic improvements in the use and acceptance of clinical computing systems and Electronic Health Records (EHRs), especially in the United States. Although there are still challenges with the implementation of such systems, the rate of progress has been remarkable. Over the next twenty-five years, there will remain many important opportunities and challenges. These opportunities include understanding complex clinical computing issues that must be studied, understood and optimized. Dramatic improvements in quality of care and patient safety must be anticipated as a result of the use of clinical information systems. These improvements will result from a closer involvement of clinical informaticians in the optimization of patient care processes.

CONCLUSIONS

Clinical information systems and computerized clinical decision support have made contributions to medicine in the past. Therefore, by using better medical knowledge, optimized clinical information systems, and computerized clinical decision, we will enable dramatic improvements in both the quality and safety of patient care in the next twenty-five years.

What Quality Metrics Is My Hospital Being Evaluated on and What Are the Consequences?

Quality, experience, and cost are important indicators of value to patients. However, stakeholders have yet to reach agreement on how to define quality and which measures should be used to assess quality. Measures that have been used to assess quality in health care include structural, process, patient experience, efficiency, and outcomes measures. Payers and other quality rating organizations use a combination of measures to rate or rank hospitals on the quality of care they provide. These ratings can be strictly informational or can be used to steer patients, for contracting between payers and providers, and more recently, for adjustments to reimbursements. Physicians and hospitals have a crucial role to play in the development of quality measures that are used to measure and improve value. Consensus on quality measures will facilitate meaningful comparisons across providers and insights that will enable improvements in the value of care we deliver to our patients.

Missing clinical and behavioral health data in a large electronic health record (EHR) system

OBJECTIVE

Recent massive investment in electronic health records (EHRs) was predicated on the assumption of improved patient safety, research capacity, and cost savings. However, most US health systems and health records are fragmented and do not share patient information. Our study compared information available in a typical EHR with more complete data from insurance claims, focusing on diagnoses, visits, and hospital care for depression and bipolar disorder.

METHODS

We included insurance plan members aged 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression (N = 5140) or bipolar disorder (N = 462). We extracted insurance claims and EHR data from the primary care site and compared diagnoses of interest, outpatient visits, and acute hospital events (overall and behavioral) between the 2 sources.

RESULTS

Patients with depression and bipolar disorder, respectively, averaged 8.4 and 14.0 days of outpatient behavioral care per year; 60% and 54% of these, respectively, were missing from the EHR because they occurred offsite. Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45% and 46% missing, respectively, from the EHR. The EHR missed 89% of acute psychiatric services. Study diagnoses were missing from the EHR's structured event data for 27.3% and 27.7% of patients.

CONCLUSION

EHRs inadequately capture mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information raises concerns about medical errors and research integrity. Given the fragmentation of health care and poor EHR interoperability, information exchange, and usability, priorities for further investment in health IT will need thoughtful reconsideration.